Assignment of Medical Care

I, (Parent / Legal Guardian) ____________________________________________________________,

residing at (Parent / Legal Guardian’s Address) _____________________________________________

__________________________________________________________________________________,

give permission for ___________________________________________________________________

and/or _____________________________________________________________________________

to seek medical care for my child(ren) (Names and Birthdays)

__________________________________________________________________________________

__________________________________________________________________________________

in the event I am unable to accompany my child(ren) to the physician’s office.

This authorization is for routine care and/or emergency care as deemed necessary by the physician and
staff of Azle Pediatrics. I understand that in the event of an extraordinary emergency, Azle Pediatrics will
make a reasonable effort to contact me and inform me of the situation.

I may be reached at the following numbers:

Home: ____________________ Work: ____________________ Cell: ____________________

I understand that this authorization is directed to the attention of Azle Pediatrics staff and to the physician
and staff who may be required to treat my child in the event Azle Pediatrics staff is absent.

_________________________________________
Signature of Parent / Legal Guardian

_________________________________________ ______________________________________
Witness Second Witness (Required if via telephone)

_________________________________________
Date